Death Record

In-hospital death documentation and death certificate generation

Patient Name

UHID

IP Number

Age / Gender

Ward / Bed

Admitted On

Date & Time of Death *

Certifying Doctor *

Manner of Death

Place of Death

Medico-Legal Case (MLC)

Immediate Cause (I a) *

Due to / Consequence of (I b)

Due to / Consequence of (I c)

Underlying Cause (II) — Contributing

Additional Clinical Notes

Body handed over to next-of-kin

Mortuary Number / Slot

Transferred By (Staff Name)

Transfer Date & Time

Notes